Community Benefit Activity Report



|Community Benefit Tracking Report |

|Submitting Department:_________________ Date:__________ |

Instructions: This form is to be used in reporting programs or services that your department provides for the benefit of the community.

• The program or service must address a community need.

• The program’s purpose is to benefit the community rather than the organization.

|What was the name of the program? |

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|Briefly describe: |

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|How did this program benefit the community? |

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|What population in this community did the program target (medically underserved, low income, minority? |

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|Provide the dates and locations of activities: |

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|How many persons were served? |

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|Attach a detail of expenses related to this program (see attached form) |

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|Were there any grants, contributions or other funds donated for this program? If so, list below. |

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|Were any community partners involved in program? If so, list: |

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|Other Comments: |

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|Contact person name, phone number and e-mail address: |

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|Community Benefit Activity Costs |

|(file one report for each activity occurrence) |

|Submit report to Accounting Office |

|Project |Project Coordinator |

|# Persons served |# Handouts |Code |  |

|Activity Date:  Activity Location:  |

|NOTE: The dollar value of time spent by salaried employees can be included if the employee is participating during “paid work time” AND if participation is clearly|

|part of the individual’s job responsibilities. |

|Complete only non-shaded areas below. |

|Personnel: |  |  |  |  | |

| Name |Dept. |Hours |Direct cost |Indirect costs | |

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|Materials: attach support |  |  |  | |

|Description |  |  |Direct cost |Indirect costs | |

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|Other expenses: attach support |  |  | |

|Description |  |  |Direct cost |Indirect costs | |

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| | | |Direct |Indirect |Total |

| |Total Costs |  |  |  | |

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